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Deficiency Records for Saint John Paul Ii Center
A list of the most recent deficiencies for Saint John Paul Ii Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Saint John Paul Ii Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-05-17 | 2023-06-23 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-05-17 | 2023-06-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-17 | 2023-06-23 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-05-17 | 2023-06-23 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-05-17 | 2023-06-23 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-05-17 | 2023-06-23 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-17 | 2023-06-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-17 | 2023-06-23 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-05-17 | 2023-06-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-17 | 2023-06-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-17 | 2023-06-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-17 | 2023-06-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-05-17 | 2023-06-23 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-05-17 | 2023-06-23 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-05-17 | 2023-06-23 | N |
| Post nurse staffing information every day. | Health | 2023-05-17 | 2023-06-23 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-05-17 | 2023-06-23 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-05-17 | 2023-06-23 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-17 | 2023-06-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-17 | 2023-06-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-17 | 2023-06-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-17 | 2023-06-23 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-05-17 | 2023-06-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-05-10 | 2023-06-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-10 | 2023-06-21 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-05-10 | 2023-06-21 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-05-10 | 2023-06-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-05-10 | 2023-06-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-10 | 2023-06-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-10 | 2023-06-21 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-05-10 | 2023-06-21 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2023-05-10 | 2023-06-21 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-05-10 | 2023-06-21 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-12-20 | 2023-01-27 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-20 | 2023-01-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-17 | 2022-09-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-20 | 2022-07-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-07-20 | 2022-07-20 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-20 | 2022-07-20 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-03-16 | 2022-04-26 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-01-20 | 2021-04-16 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-01-20 | 2021-04-16 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-01-26 | 2021-03-04 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-01-26 | 2021-03-04 | N |
| Report COVID19 data to residents and families. | Health | 2021-01-26 | 2021-03-04 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-02-07 | 2019-03-19 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-02-07 | 2019-03-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-02-07 | 2019-03-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-02-07 | 2019-03-19 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-02-07 | 2019-03-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-07 | 2019-03-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-02-07 | 2019-03-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-07 | 2019-03-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-07 | 2019-03-19 | N |
| Dispose of garbage and refuse properly. | Health | 2019-02-07 | 2019-03-19 | N |
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